Diagnostic and coding errors on the first page of medical records from a tertiary hospital in Shenzhen
10.3969/j.issn.1671-332X.2024.11.021
- VernacularTitle:深圳市某三级医院病案首页诊断及编码缺陷分析
- Author:
Yong TAO
1
;
Ning ZHANG
;
Wenjie WANG
;
Zejin LIN
;
Renyong LIN
Author Information
1. 深圳市龙华区中心医院 广东 深圳 518000
- Keywords:
First pages of medical records;
Primary diagnosis;
Coding errors;
Surgical procedures
- From:
Modern Hospital
2024;24(11):1710-1712
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze flaws in diagnosis and coding of diseases on the first pages of inpatient medical records and explore solutions to improve the accuracy of record-filling in tertiary hospitals.Methods A retrospective analysis was con-ducted to assess the quality control and logical verification data from the first pages of inpatient records at a tertiary hospital,col-lected from January to December 2023.Results A total of 463 flaws were identified,including 99 flaws in primary diagnostic selection,accounting for 21.37％,148 flaws in primary surgical selection accounting for 32.00％,33 omissions in secondary di-agnoses,accounting for 7.12％,and 121 omissions in surgical procedures accounting for 26.12％.Primary diagnostic errors were primarily attributed to failure to specify etiology,with the highest number of 24 cases(24.24％),followed by overgeneral-ized diagnostic descriptions,with 15 cases(15.15％).Totally,169 coding errors were identified,including 61 logic errors(36.09％),58 coding omissions(34.33％),and 30 uncombined coding cases(17.75％).Conclusion There are significant flaws in the coding on the first pages of medical records.It is imperative to strengthen the training for clinicians and coders and enhance quality control through intelligent automation.These measures are crucial for improving the quality control of the first pa-ges of medical records.
